The Influence of Oral Hygienic

Habits on Non-Carious Cervical

Lesion Development

Summary
The aim of this study was to assess the influence of certain oral
hygienic habits (such as general hygiene of the mouth, frequency of
toothbrushing, toothbrush hardness) on non-carious lesion development. The study was conducted on 873 subjects, aged 10 yrs or older.
Results showed that there is a statistically significant difference regarding oral hygiene between subjects with cervical lesions and those without them. Furthermore, there is no statistically significant difference
in non-carious cervical lesion development regarding frequency of toothbrushing and toothbrush hardness.
Key words: hygiene, habits, non-carious cervical lesion.

Introduction

1Department

of Dental
Prosthodontics
Medical Faculty of Rijeka
Study of Dentistry, Croatia
2Department of Dental
Pathology
Medical Faculty of Rijeka
School of Dentistry, Croatia

Acta Stomat Croat

2004; 167-170

ORIGINAL SCIENTIFIC
PAPER
Received: April 19, 2004
Address for correspondence:
Mr. sc. Josipa Bori, dr. stom.
Medical Faculty of Rijeka
Kreimirova 40, 51000 Rijeka
phone: +385 51 213255
e-mail:
josipa.borcic@ri.htnet.hr

to be the second major cause regarding frequency.

It has been quoted that as many as 25% of pathological destructions are caused by non-carious processes (3). Such processes include atrition, abrasion,
erosion, localized non-hereditary enamel hypocalcification, localized non-hereditary dentinal hypocalcification, localized non-hereditary dentinal hypoplasia, discolorations, malformations, amelogenesis
imperfecta, dentinogenesis imperfecta, and tooth
trauma.
Because of its morphology the cervical part of
the tooth is considered a plaque-retaining spot since
it is the narrowest part of the tooth, and also because
it is in the proximity of the gingival margin which
makes physiological saliva washing and mechani-

Non-carious cervical lesion (NCCL) is defined

as loss of mineralized tooth tissue on enamelocemental junction which is not of carious origin, can
be caused by a number of various factors, and is
most frequently found on plaque-free surfaces. Such
physical and chemical loss of sound tooth structure
can cause painful hypersensitivity, painful sensations, pathological pulp changes, and finally tooth
loss (1). Commonly literature offers descriptions
of all non-carious lesions as if they were one entity; usually they begin with a desciption of tooth
substance loss (2). Following caries as the main
cause of such changes, cervical lesions are thought
Acta Stomatol Croat, Vol. 38, br. 3, 2004.

Josipa Bori1
Robert Antoni1
Miranda Muhvi-Urek1
Davor Dori1
Jelena Horvat2

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The Influence of Oral Hygienic Habits on Non-Carious Cervical Lesion Development

cal cleaning difficult (4). Such morphology facilitates plaque and calculus accumulation, which can
lead to inflammation, gingival recession, and a
change in the physiological root - to - crown ratio.
Literature offers confusing statements as to whether
the method of brushing can cause such abrasion.
Some studies confirm this hypothesis, some reject
it (5).

for all the subjects. Oral hygiene was denoted as

good, average or poor, while subjects were divided
into groups depending on sex and non-carious lesion
occurrence.
Of the 873 subjects tested, 276 were men and 342
women with non-carious cervical lesions, while 117
men and 138 women had no such lesions. Of the 276
men with NCCL, 105 (38%) had good oral hygiene,
91 (33%) average, and 80 (29%) poor oral hygiene.
Of the men without NCCL, 63 (53.9%) had good
hygiene, 17 (14.5%) average, and 37 (31.6%) poor
oral hygiene. Of the 342 women with NCCL, 147
(43%) had good oral hygiene, 129 (37.7%) average,
and 66 (19.3%) poor oral hygiene. Of the 138
women without NCCL, 102 (73.9%) had good
hygiene, 24 (17.4%) average, and 12 (8.7%) poor
oral hygiene.

The aim of this study was to evaluate the effect

of certain hygienic habits (such as general hygienic status of the mouth, frequency of toothbrushing,
toothbrush hardness) on NCCL development.

Materials and Methods

873 subjects were included in this study, aged 10
yrs or older, randomly selected in dental practices
where the study was conducted. Of those tested, 435
were men and 567 women.

Using 2 test for statistical analysis at df = 2, and

p < 0.05, the value of 2 was 46.22. We concluded
that there was statistically significant difference
regarding oral hygiene between the subjects with
NCCLs and those without such lesions. It can be
stated that subjects without NCCLs had better oral
hygiene in comparison to those with NCCLs.

First all relevant general data on patients were

collected: first and last name, sex, year of birth,
phone number, degree, and details of clinical examination. Oral and dental hygiene were graded on the
subjective basis, in terms of good, average, and poor.
Teeth with no plaque were graded as hygienically
good. Teeth with plaque covering up to 1/3 of posterior teeth surfaces were graded as hygienically
average, and teeth with plaque covering anterior
teeth as well as posterior were graded as hygienically poor. Examinations were performed by one
investigator only. Teeth with non-carious cervical
lesions were marked with +, while teeth without
such lesions were marked with .

2. The relationship between frequency of

toothbrushing and NCCL development
All the subjects (873) were divided into two
groups: those with NCCLs and those without
NCCLs. Frequency of toothbrushing was noted in
both groups. The following results were obtained:
21 subjects brushed their teeth less than once a day,
243 subjects brushed once a day, 438 brushed twice
a day, and 171 brushed three or more times a day.
Of the 618 subjects with NCCLs, 12 (1.94%) brushed
their teeth less than once a day, 180 (29.13%)
brushed once a day, 312 (50.49%) brushed twice a
day, and 114 (17.96%) brushed three or more times
a day. Of those subjects negative for NCCLs (255),
9 (3.53%) brushed their teeth less than once a day,
63 (24.71%) brushed once a day, 126 (49.41%)
brushed twice a day, and 57 (22.35%) brushed three
or more times a day.

In the next phase original anamnestic charts were

completed, which consisted of 3 questions. Patients
were asked to choose one of the answers offered.
Questions regarded frequency of toothbrushing and
the type of toothbrush used.

Results
1. The relationship between oral hygiene and
non-carious lesion development

The value of 2 calculated was 4.6 (df = 3, p < 0.05)

which confirms that there were no statistically significant differences in NCCL development depending on the frequency of toothbrushing.

The relationship between oral hygiene and a finding of non-carious cervical lesions was established
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The Influence of Oral Hygienic Habits on Non-Carious Cervical Lesion Development

3. The relationship between toothbrush hardness

and NCCL development

McClure found in 1949 that 27% of the subjects

were affected (17), while Bergstrm and Lavstedt
published their finding that cervical abrasion occurred in 31% of the population (18). The data listed
agree with our findings to a certain point, where
the incidence of NCCL occurrence is 35.6% in the
first age group, 73.9% in the second, 94.6% in the
third, 78.8% in the fourth, 66.7% in the fifth, and
78.6% in the sixth age group. Such variation, e.g.
smaller percentage of the people affected after 46
yrs of age could be explained by the loss of teeth
in older age groups, particularly those that are most
commonly affected by the described lesions. According to Graehn, 23% of the patients subjected to a
dental examination had cuneiform defects (19). He
also had six age groups, although in his first age
group consisted of patients of 14 yrs or younger,
who had no NCCL. In the second age group were
patients aged 15-19 yrs and 3.1% of them had
cuneiform defects. In the third age group (20-27 yrs
of age) the occurrence of NCCLs was 17.5%, while
in the fourth group (30-44 yrs) it was 22.7%. The
fifth age group consisted of patients aged 45-64 yrs
and 50.5% of those had NCCLs. Finally, in the sixth
age group (65 and older) only 6.2% of the patients
had NCCLs. It can be observed that, as in our investigation, the percentage of patients affected diminished in the older age groups. Donachie (20) did not
give such information, although he stated that there
is a significant increase in cervical region substance
loss with age, additionally noting that men were more
affected than women.

The number of subjects who did not brush their

teeth (e.g. who brushed less than once a day) was
deducted from the total number of subjects. Thus
the relevant number of subjects was 852. Of those,
119 used a hard toothbrush, 688 used a toothbrush
of medium hardness, and 45 used a soft toothbrush.
Of the 606 subjects with NCCL, 80 (13.2%) used a
hard toothbrush, 493 (81.35%) used a toothbrush
of medium hardness, and 33 (5.45%) used a soft
toothbrush. Among the 246 subjects without NCCL,
39 (15.85%) used a hard toothbrush, 195 (79.27%)
used a medium-hard toothbrush, and 12 (4.88%) used
a soft toothbrush.
Statistical analysis using 2 test showed that the
value of 2 was 2.14 (df = 2, p < 0.05), which shows
no statistically significant difference in NCCL development regarding toothbrush hardness. It can be
stated that toothbrush hardness does not influence
NCCL development.

Discussion
NCCL pathogenesis was a hot topic for all of
the last century, and still some contradictions and
incoherences remain. Beside epidemiological studies, some investigations have focussed on the best
therapy for such disease (6-8), or the influence of
various etiological factors (9-11). Data that emerged
from such investigations are in agreement with those
by Lussi and Schaffner (12) who observed that
60.8% of the population in Switzerland are affected by cuneiform defects. These values are similar to
those obtained by Bergstrm and Eliasson (13) who
found that 67% of people aged 21-30 yrs had tooth
abrasion, while 90% of those aged 31-60 yrs had the
same defects. Jrvinen (14) found dental erosions in
only 5% of Finnish population, which could be
caused by higher inclusion criteria applied and
exclusion of types of cervical lesions not caused by
erosive factors. Kitchin found in his investigation of
1941 that the occurrence of abrasion was 42% in
people aged 20-39 yrs, and 76% in people aged 4059 yrs (15). Ervin and Bucher published their results
in 1952 stating that such lesions occur in 45-87% of
the population, depending on age (16). Zipkin and
Acta Stomatol Croat, Vol. 38, br. 3, 2004.

It is a common belief that NCCLs occur more

often in patients with good oral hygiene, which can
be caused by toothbrush hardness or toothpaste abrasiveness. However, the results obtained do not sustain this theory since we found that people with poor
oral hygiene had a lower occurrence of NCCLs.
Expressed in percentages, men without NCCLs had
good oral hygiene in 53.9% of cases, average hygiene in 14.5%, and poor hygiene in 31.6%. Men with
NCCLs had good oral hygiene in 38% of the cases,
average in 33%, and poor hygiene in 29 %. Among
the women those differences were even more pronounced: 73.9% of the women without NCCLs had
good oral hygiene, 17.4% average, and 8.7% poor
oral hygiene. Of the women with NCCLs, 43% had
good oral hygiene, 37.7% average, and 19.3% poor
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The Influence of Oral Hygienic Habits on Non-Carious Cervical Lesion Development

hygiene. We can observe that differences are smaller in those patients with poor oral hygiene, e.g. percentages are similar, which is probably caused by
greater plaque index in the population with poor oral
hygiene, leading to greater tooth loss. Sorvari (21)
experimentally proved that fluoridated tooth surface
is significantly more resistant to the detrimental
effects of acids. Topical application of fluorides can
inhibit initial erosion. This mechanism explains the
results we obtained, that good oral hygiene means
less frequent NCCLs, since most of todays toothpastes are fluoridated. Kuroiwa (22) suggests that
brushing should be performed without using toothpaste because the tooth surface is protected by organic pellicule which is a reservoir for minerals that
incorporate into enamel. If toothpaste is used, abrasive particles create microdamage that serves as a
nidus for plaque accumulation or cause microcracks
of enamel prisms. According to our results frequency
of brushing and toothbrush hardness do not affect

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NCCL development. Van der Mei (9) proved that

abrasion can lead to NCCL development in vitro.
Bergstrm and Lavstedt (18) found a statistically
significant difference in cervical lesion frequency
between those patients who brushed twice a day and
those who brushed less frequently. The same authors
published in one of their earlier studies that toothbrush hardness did not significantly affect cervical
lesion development (23).
Considering the large number of studies in which
authors claim that the toothbrush causes NCCL
development, and others that claim the opposite, we
cannot completely exclude the role of the toothbrush
as one of the etiological factors. However, Floyd
found cervical lesions in cats (24) which eliminates
the role of toothbrushing as an etiological factor.
However, as we know, NCCLs can be caused by a
number of various factors, and mechanical irritation
is probably one of the components in this complex
system of cervical lesion development.

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Acta Stomatol Croat, Vol. 38, br. 3, 2004.